- ALL RIGHT. WE CAN GO
AND GET STARTED.
I WOULD LIKE TO WELCOME YOU ALL
TO OUR FIRST CALL
OF THE FISCAL YEAR
IN THE 2013 EPILEPSY PATIENT
AUDIO CALL SERIES.
MY NAME IS SEAN GAMBLE
AND I AM WITH
THE EMPLOYEE EDUCATION
SERVICES OF ST. LOUIS,
AND I'M THE PROJECT
MANAGER FOR THE SERIES.
OUR LINES ARE MUTED
AND WILL BE OPENED UP
AT THE END OF THE PRESENTATION
WHEN WE ARE READY FOR QUESTIONS.
PLEASE LIMIT YOUR QUESTIONS
TO ENSURE EVERYONE HAS A CHANCE
TO ASK ANY THAT THEY MAY HAVE.
PLEASE BE SURE TO COMPLETE
YOUR EVALUATION.
YOU GET CREDIT FOR THIS PROGRAM.
COMPLETE INSTRUCTIONS ARE
FOUND IN THE BROCHURE
OR ON THE CATALOG AT CMS.
YOUR DEADLINE TO FINISH
THESE IS DECEMBER 20th.
NOW LET ME WELCOME
OUR SPEAKER FOR TODAY,
DR. CHRISTOPHER RANSOM.
DR. RANSOM, IT'S ALL YOURS.
- OK, THANK YOU, SEAN.
SO, AS SEAN MENTIONED,
I'M CHRIS RANSOM.
I'M AN EPILEPTOLOGIST
AT THE VA-PUGET SOUND,
PART OF THE EPILEPSY CENTER
OF EXCELLENCE HERE.
AND THE TOPIC I'M GOING
TO DISCUSS TODAY IS
EPILEPSY AND SEIZURES,
WHICH IS KIND OF A BASIC SET
OF INFORMATION I WANT
TO SHARE WITH PEOPLE.
MANY OF THE AUDIENCE ARE
FAMILIAR WITH THE TOPICS
I'M GOING TO SPEAK ABOUT, BUT I
THINK IT'S IMPORTANT TO ALWAYS
REFRESH OURSELVES ABOUT REALLY
SOME REAL BASIC CONCEPTS
ABOUT EPILEPSY AND SEIZURES
BECAUSE EVERY ONCE IN A WHILE,
YOU KNOW, I SEE PATIENTS THAT
SAY, "WELL, YOU SAID EPILEPSY.
WHAT DOES THAT MEAN?"
SO I THINK IT IS CRUCIAL
THAT EVERYONE UNDERSTANDS
WHAT THEIR POSITIONS ARE
WHEN TALKING ABOUT--
WHEN THEY'RE REFERRING
TO EPILEPTIC SEIZURES
AND EPILEPSY.
AND SO I'M GOING TO ORGANIZE
MY TALK REALLY ALONG THE LINES
OF THE OUTCOME OBJECTIVES, WHICH
WERE LISTED ON THE BROCHURE.
SO, WHAT IS A SEIZURE?
THIS IS A DEFINITION THAT WAS
PUT FORTH BY HUGHLINGS JACKSON
IN 1870; ALWAYS AMAZES ME.
HUGHLINGS JACKSON WAS A REAL
PIONEER OF BRITISH NEUROLOGY,
AND HE MADE THIS DEFINITION
BEFORE HE EVEN KNEW
ABOUT ELECTRICAL ACTIVITY
IN THE BRAIN.
AND HIS DEFINITION IS THAT
A SEIZURE IS "AN OCCASIONAL,
"AN EXCESSIVE, AND
A DISORDERLY DISCHARGE
OF CEREBRAL NERVOUS
TISSUE UPON MUSCLE."
WE'VE LEARNED A TREMENDOUS
AMOUNT ABOUT THE BRAIN
AND EPILEPTIC SEIZURES,
BUT WE CAN HARDLY IMPROVE
ON THAT DEFINITION.
BUT TO REFINE THIS,
AN EPILEPTIC SEIZURE RESULTS
FROM AN ABNORMALLY SYNCHRONIZED
AND HIGH-FREQUENCY FIRING
OF NEURONS IN THE BRAIN,
OR NERVE CELLS, THAT RESULTS
IN ABNORMAL BEHAVIOR
OR EXPERIENCE OF THE INDIVIDUAL.
SO THIS IS AN ELECTRICAL EVENT.
THE BRAIN IS AN ELECTRICAL
DEVICE, AND WHEN THIS
ELECTRICITY DEVELOPS
A HIGHER AMPLITUDE
OR ABNORMAL PATTERN,
IT PRODUCES THE SIGNS
AND SYMPTOMS OF A SEIZURE.
AND DIFFERENT PARTS OF OUR BRAIN
DO DIFFERENT FUNCTIONS,
SO THE EXPERIENCES OF
AN INDIVIDUAL AND THE SYMPTOMS
THAT ARE SEEN DURING
THE SEIZURE ALL RELATE
TO WHICH PART
OF THE BRAIN IS AFFECTED.
FOR EXAMPLE, SEIZURES
THAT INVOLVE THE FRONTAL LOBE,
WHICH IS AN AREA THAT IS
INVOLVED WITH MOVEMENT,
OFTEN SHOW DRAMATIC MOVEMENTS
OF THE LIMBS AND WHAT WE CALL
MOTOR ACTIVITY, WHEREAS SEIZURES
THAT INVOLVE THE TEMPORAL LOBE
OFTEN DON'T PRODUCE A LOT
OF PROMINENT MOVEMENT,
BUT INVOLVE EXPERIENCES
THAT THE INDIVIDUAL WILL FEEL,
SUCH AS A DEJA VU.
SOMETIMES PEOPLE EXPERIENCE
AN EPIGASTRIC RISING SENSATION
LIKE BEING ON
A ROLLER COASTER.
SOMETIMES THEY PRODUCE JUST
A BLAND LOSS OF AWARENESS
AND RESPONSIVENESS.
LIKEWISE, THE OCCIPITAL LOBE,
WHICH IS INVOLVED IN VISION,
SEIZURES THAT BEGIN THERE
OFTEN PRODUCE VISUAL SYMPTOMS:
EITHER FLASHING LIGHTS OR PEOPLE
LOSE PART OF THEIR VISUAL FIELD.
SOMETIMES PEOPLE DESCRIBE
JUST SEEING BLOBS OF COLOR
AND ELEMENTARY SHAPES,
AND THESE ARE ALL PRODUCED--
ALL THE SYMPTOMS
I MENTIONED ARE PRODUCED
BY THIS ABNORMALLY SYNCHRONIZED
AND HIGH-FREQUENCY FIRING
OF NEURONS IN THE BRAIN.
SO A SINGLE SEIZURE IS COMMON.
IT'S ESTIMATED THAT UP
TO 10% TO 15% OF INDIVIDUALS
WILL HAVE A SEIZURE
AT SOME TIME DURING THEIR LIFE.
AND I SAY "A SEIZURE"
BECAUSE MOST OF THESE ARE
WHAT WE CALL PROVOKED SEIZURES.
THEY ARE DUE TO AN ACUTE
AND REVERSIBLE PROBLEM
SUCH AS A SYSTEMIC ILLNESS.
COMMON CAUSES OF PROVOKED
SEIZURES ARE HYPOGLYCEMIA.
PROFOUNDLY LOW DROPS
IN BLOOD SUGAR
HAVE THE ABILITY
TO PRODUCE SEIZURES.
OCCASIONALLY WE SEE
PROVOKED SEIZURES DUE
TO ALCOHOL OR DRUG INTOXICATION
OR WITHDRAWAL, AND I THINK
THAT'S A KEY PHRASE, THAT THESE
ARE PROVOKED SEIZURES.
THEY ARE CAUSED BY A SPECIFIC
CAUSE THAT'S REVERSIBLE,
AND THAT'S IN CONTRAST
TO THE CONDITION OF EPILEPSY.
EPILEPSY IS A DISORDER
IN WHICH THERE IS A TENDENCY
TO HAVE RECURRENT,
UNPROVOKED SEIZURES.
SO THESE ARE SEIZURES
THAT OCCUR WITHOUT WARNING
AND WITHOUT ANY IMMEDIATELY
IDENTIFIABLE CAUSE.
IN CONTRAST TO THE 10%
TO 15% OF PEOPLE
THAT WILL HAVE A SEIZURE
DURING THEIR LIFETIME,
A PROVOKED SEIZURE,
EPILEPSY AFFECTS
ABOUT 1% OF THE GENERAL
POPULATION.
AND 1% IS A SMALL NUMBER,
BUT THIS AMOUNTS TO
A VERY LARGE INCIDENCE
OF EPILEPSY, A PREVALENCE.
SO IT'S ESTIMATED THAT,
YOU KNOW, SO THIS IS
A COMMON CHRONIC
MEDICAL CONDITION,
ONE OF THE MORE COMMON
DISORDERS IN NEUROLOGY.
IT'S ESTIMATED THAT
ABOUT 50 MILLION PEOPLE
WORLDWIDE HAVE EPILEPSY,
AND 2.4 MILLION NEW CASES
ARE DIAGNOSED EACH YEAR.
FORTUNATELY, MOST PEOPLE SHOULD
HAVE THEIR SEIZURES CONTROLLED
WITH MEDICATION AND ARE ABLE
TO LIVE VERY NORMAL LIVES
AND CONTINUE THEIR ACTIVITIES.
SO HOW DO WE DISTINGUISH
BETWEEN PROVOKED SEIZURES
AND UNPROVOKED SEIZURES
IN EPILEPSY?
SO ONE IS JUST THE CHARACTER
OF THE SEIZURES, WHAT IS SEEN.
ANYONE WHO HAS A FAMILY MEMBER
OR FRIEND WITH EPILEPSY,
IT'S--THESE ARE--
IF YOU SEE A SEIZURE,
THESE ARE OBVIOUSLY
DISTURBING EVENTS,
BUT I ENCOURAGE EVERYONE TO TRY
TO BE A GOOD OBSERVER
BECAUSE DOCTORS THAT ARE
EVALUATING PEOPLE WITH SEIZURES
AND EPILEPSY WERE OFTEN RELYING
SOLELY ON THE DESCRIPTION
PROVIDED TO US OF
WHAT PEOPLE SEE.
SO I DO ENCOURAGE EVERYONE
TO TRY AS BEST AS THEY MAY
TO OBSERVE WHAT'S HAPPENING
AND CATALOG AND REMEMBER THIS
BECAUSE THIS IS INVALUABLE
INFORMATION TO PHYSICIANS
THAT ARE TREATING SEIZURES.
SO USUALLY SEIZURES
ARE STEREOTYPED.
THAT MEANS THAT THEY ARE
VERY SIMILAR ONE TO THE NEXT,
AND IN THE HOSPITAL, IF WE WERE
ABLE TO RECORD SEIZURES
WITH VIDEO EEG MONITORING,
YOU SEE THAT IF WE RECORD
SEVERAL SEIZURES,
THEY'RE NEARLY IDENTICAL
ONE TO THE OTHER,
SO THEY'RE USUALLY
HIGHLY STEREOTYPED.
SEIZURES ARE
ALSO TYPICALLY BRIEF,
LASTING BETWEEN 10 SECONDS
TO TWO MINUTES.
SEIZURES THAT LAST LONGER
THAN TWO MINUTES
ARE VERY UNCOMMON.
THE BEHAVIORS THAT PEOPLE
EXHIBIT DURING
EPILEPTIC SEIZURES
ARE OFTEN REPETITIVE.
SOMETIMES PEOPLE HAVE
PURPOSEFUL HAND MOVEMENTS
THAT WE TERM AUTOMATISM.
OCCASIONALLY PEOPLE WILL HAVE
FLEXION OF A SINGLE LIMB
OR TURN THEIR HEAD
ONE WAY OR THE OTHER,
AND THOSE ARE FEATURES
THAT ARE IMPORTANT
FOR PHYSICIANS TO UNDERSTAND.
SEIZURES ALSO HAVE
AN EVOLUTION AND EITHER HAVE
A CRESCENDO TO
PRE-CRESCENDO PATTERN.
SO THE BEGINNING OF THE SEIZURE
OFTEN LOOKS VERY DIFFERENT
IN TERMS OF WHAT
AN INDIVIDUAL'S EXPERIENCING
OR WHAT THEIR BEHAVIOR LOOKS
LIKE THAT'S DIFFERENT
THAN IT IS AT THE END
OF THE SEIZURE.
SO WE EXPECT
TO BE SOME EVOLUTION
OF THE BEHAVIORING CENTER DURING
THE COURSE OF THE SEIZURE.
THE OTHER FEATURE
OF EPILEPTIC SEIZURE IS
THAT THEY OCCUR RANDOMLY
AND UNEXPECTEDLY, WHICH IS
OBVIOUSLY ONE OF THE MOST
CHALLENGING, DISABLING,
AND ANXIETY-PROVOKING
FEATURES OF THE ILLNESS.
ALTHOUGH THESE ARE SOME THINGS
THAT WE EXPECT TO SEE
OF EPILEPTIC SEIZURES,
THERE ARE MANY EXCEPTIONS,
SO OFTEN MAKING THE DIAGNOSIS
OF SEIZURES AND EPILEPSY
ON CLINICAL GROUNDS ALONE
IS PRACTICALLY IMPOSSIBLE
AND WE'LL NEED TO DO
ADDITIONAL EVALUATION.
AND SO THE THINGS THAT WE THINK
ABOUT--THEY CAN LOOK
ALL THE WORLD LIKE
AN EPILEPTIC SEIZURE;
THERE ARE SEVERAL
DIFFERENT CONDITIONS.
ONE OF THE MOST COMMON IS
SYNCOPE, OR SIMPLY FAINTING,
AND, YOU KNOW, THIS CAUSES
SOMEONE TO PASS OUT AND THEN
FALL TO THE GROUND,
AND OCCASIONALLY THERE CAN BE
SOME MOVEMENTS ASSOCIATED
WITH THIS PASSING OUT
THAT CAN EASILY BE
CONFUSED FOR A SEIZURE.
SYNCOPE COMMONLY IS DUE
TO DROPS IN BLOOD PRESSURE,
SUCH AS EVEN STANDING UP
TOO QUICKLY AFTER BEING SEATED
FOR A WHILE, OR CARDIAC
DYSRHYTHMIA--
THE ABNORMAL HEART
RHYTHMS--AND OTHER CAUSES.
AND THEN--SO THAT'S ONE
OF THE BIG THINGS
THAT PHYSICIANS ARE ALWAYS
TRYING TO DISTINGUISH BETWEEN,
ARE SEIZURES AND SYNCOPE.
THESE TWO THINGS HAVE VERY
DIFFERENT TREATMENTS.
TRANSIENT ISCHEMIC ATTACKS,
OR SMALL STROKES,
CAN OFTEN MIMIC AS A SEIZURE AND
CAN BE CONFUSED FOR A SEIZURE.
I MENTIONED SOME METABOLIC
DISORDERS SUCH AS HYPOGLYCEMIA,
WHICH CAN PRODUCE SYMPTOMS
THAT LOOK LIKE A SEIZURE.
SOME TYPES OF MIGRAINE HEADACHES
CAN CAUSE SYMPTOMS
THAT WILL BE MISTAKEN
FOR A SEIZURE.
THERE'S ALSO SOME MORE RARE
TYPES OF SLEEP DISORDERS
AND MOVEMENT DISORDERS
THAT ARE FREQUENTLY MISTAKEN
FOR SEIZURES, AND THESE ARE
THINGS THAT PHYSICIANS TRY
TO DISTINGUISH BEFORE
DECIDING ON A THERAPY.
LASTLY, I'LL JUST MENTION
THAT...PSYCHIATRIC CAUSES
AND CHANGES IN BEHAVIOR ARE
VERY COMMON, AND WE TERM THIS
CONVERSION DISORDER,
AND THESE CAN PRODUCE
WHAT WE CALL PSYCHOGENIC
NON-EPILEPTIC SEIZURES.
AND THIS IS ONE OF
THE CONDITIONS THAT IS
FREQUENTLY DIAGNOSED
IN VIDEO EEG-MONITORING
AND IT'S ABOUT--WORLDWIDE,
ABOUT HALF THE CASES SUBMITTED
TO VIDEO EEG-MONITORING UNITS
END UP BEING DIAGNOSED
WITH PSYCHOGENIC
NON-EPILEPTIC SEIZURES
AND NOT EPILEPTIC SEIZURES.
AND THAT'S A REALLY
IMPORTANT THING TO DETERMINE
BECAUSE FREQUENTLY
PEOPLE ARE TREATED
WITH ANTI-EPILEPTIC DRUGS, UP TO
2 OR 3 DIFFERENT MEDICATIONS,
THAT ARE NOT HELPING
STOP THE EVENT.
SO IT'S REALLY CRUCIAL
TO DISTINGUISH BETWEEN
THESE TWO TYPES OF THINGS AND
ESTABLISH APPROPRIATE THERAPIES.
SO HOW DO WE DIAGNOSE EPILEPSY
OR SEIZURES IN EPILEPSY?
SO THERE'S ALWAYS--
WE ALWAYS START
WITH A GOOD HISTORY
AND PHYSICAL.
THAT'S WHAT I WAS STRESSING
ABOUT, BEING OBSERVERS
ABOUT WHAT HAPPENS
DURING A SEIZURE
BECAUSE WE RELY HEAVILY
UPON THESE DESCRIPTIONS.
SO A GOOD HISTORY AND PHYSICAL,
AND WE ALSO EXPLORE
RISK FACTORS FOR EPILEPTIC
SEIZURES IN THE HISTORY,
WHICH I'LL COMMENT ON BRIEFLY.
TYPICALLY, PEOPLE HAVE A KIND
OF A GENERAL MEDICAL EVALUATION,
WHICH WOULD INCLUDE,
IN ADDITION TO A PHYSICAL EXAM,
SOME BASIC BLOOD WORK.
WE OFTEN SCREEN FOR...FOR DRUGS
AND OTHER TOXIC SUBSTANCES
WHICH HAVE THE CAPACITY
TO PRODUCE SYMPTOMS
THAT WOULD LOOK LIKE
A SEIZURE.
BUT THE MAINSTAYS
OF DIAGNOSING SEIZURES
AND EPILEPSY INVOLVES
AN ELECTROENCEPHALOGRAM,
OR AN EEG, TO INTERPRET
BRAIN WAVE PATTERNS.
THESE ELECTRICAL BRAIN WAVES
HAVE A CHARACTERISTIC
FREQUENCY AND APPEARANCE.
AND IN MANY TYPES
OF EPILEPSY, WE CAN SEE
ABNORMAL ELECTRICAL PATTERNS
ACROSS THE ENTIRE BRAIN
OR EVEN OVER A SPECIFIC
AREA OF THE BRAIN.
AND I MENTIONED THOSE TWO
DIFFERENT FINDINGS
WE MAY FIND ON THE EEG
IN PEOPLE WITH EPILEPSY
BECAUSE THOSE LEAD TO DIAGNOSIS
OF THE TYPE OF EPILEPSY
AND THE TYPE
OF SEIZURE SOMEONE HAS.
SO SOMETIMES THE EEG PATTERNS
ARE...APPEARING BILATERALLY,
ON BOTH SIDES OF THE BRAIN
AT THE SAME TIME,
AND SOMETIMES THEY CAN BE
LOCALIZED OR SPECIFIC AREAS
OF THE BRAIN, AND I'LL SPEAK
MORE ABOUT THOSE IN A MOMENT.
THE SECOND CRUCIAL ELEMENT
TO EVALUATION OF SEIZURES
AND EPILEPSY IS SOME TYPE
OF NEURO-IMAGING TEST,
PREFERABLY MRI.
AND THIS GIVES US DETAILED
STRUCTURAL INFORMATION
ABOUT THE BRAIN,
WHICH WILL HELP US IDENTIFY
THE RISK FOR RECURRENCE
OF THE SEIZURES.
IF SOMEONE PRESENTS WITH
A FIRST SEIZURE AND RECEIVES--
THEY HAVE A NORMAL EEG
AND A NORMAL MRI,
LARGE STUDIES TELL US THAT
THE RISK OF SEIZURE RECURRENCE
IS PROBABLY IN THE RANGE
OF 20% TO 30%.
SO IN THAT SITUATION...
OCCASIONALLY PEOPLE DON'T START
ANTI-EPILEPTIC MEDICATIONS
RIGHT AWAY, BUT IT DEFINITELY
DEPENDS ON THE SITUATION,
WHAT SOMEONE DOES FOR EMPLOYMENT
AND THE PATIENT'S WISHES.
MOST PHYSICIANS REALLY MAKE
THIS DECISION THE PATIENT'S
AND FEEL IT'S THEIR JOB
TO PROVIDE AS MUCH INFORMATION
AND THEN COME UP WITH A PLAN
TOGETHER THAT'S APPROPRIATE.
THAT'S NOT ALWAYS THE CASE;
SOMETIMES PHYSICIANS
WILL HAVE VERY STRONG
RECOMMENDATIONS ABOUT
WHETHER OR NOT SOMEONE NEEDS
TO BEGIN MEDICATIONS.
MRI, IF IT'S NOT NORMAL,
CAN HELP US PREDICT...
BOTH THE RISK OF RECURRENCE AND
ALSO HELPS US TO FIND THE TYPE
OF SEIZURE AND EPILEPSY
AN INDIVIDUAL HAS EXPERIENCED.
FOR EXAMPLE...IN ELDERLY PEOPLE,
PEOPLE THAT ARE OLDER IN LIFE,
STROKES AND BRAIN TUMORS ARE
AN IMPORTANT CAUSE OF SEIZURES.
AND IF WE WERE TO MAKE
THOSE FINDINGS ON AN EEG,
THAT WOULD DEFINITELY
SUPPORT THE DIAGNOSIS
OF SEIZURES AND EPILEPSY AND
ALMOST ALWAYS WOULD LEAD TO
THE RECOMMENDATION OF BEGINNING
AN ANTI-EPILEPTIC MEDICATION.
AT THIS POINT, IF WE DON'T
HAVE A CLEAR ANSWER
ABOUT WHETHER
OR NOT THE SYMPTOMS THAT
THE INDIVIDUAL IS EXPERIENCING
ARE DUE TO EPILEPTIC SEIZURES,
ADDITIONAL TESTS ARE
USUALLY RECOMMENDED.
AND THE MOST IMPORTANT ONE
IS CONTINUOUS AUDIO-VISUAL
EEG-MONITORING, AND SOME OF YOU
MAY BE FAMILIAR WITH THIS
OR HAVE ACTUALLY UNDERGONE
THIS TYPE OF TEST,
BUT IT INVOLVES ADMITTING
AN INDIVIDUAL TO THE HOSPITAL,
WHERE THEY ARE KEPT IN
A SPECIAL ROOM THAT'S EQUIPPED
WITH EEG EQUIPMENT
AND A VIDEO CAMERA.
AND THE GOAL OF THIS IS TO HAVE
AN INDIVIDUAL IN THE HOSPITAL
WITH EEG RECORDINGS BEING MADE
AND VIDEO RECORDING BEING MADE
WHILE THEY SUFFER ONE
OF THEIR SPELLS.
AND IF WE DO THIS, WE ALMOST
ALWAYS CAN MAKE A DIAGNOSIS.
IT'S NOT ALWAYS EPILEPSY,
BUT RECORDING THE VIDEO EEG DATA
DURING A SPELL GIVES US
THE INFORMATION
ABOUT WHETHER THERE'S
ABNORMAL ELECTRICAL PATTERNS
DURING THE EVENT, WHICH WOULD
SIGNIFY AN EPILEPTIC SEIZURE.
IT ALSO ALLOWS US
TO ANALYZE IN DETAIL
THE CLINICAL FEATURES,
THE BEHAVIOR AND SYMPTOMS
THAT HAPPEN DURING THE SEIZURE,
AND THAT'S ALMOST
AS IMPORTANT AS THE EEG.
WE'VE LEARNED A GREAT DEAL
ABOUT WHAT TYPES OF BEHAVIORS
AND SIGNS ARE PRODUCED
BY EPILEPTIC SEIZURES,
SO THAT'S ANOTHER CRUCIAL
ELEMENT TO THE VIDEO EEG STUDY.
IF THIS DOESN'T PROVIDE ANY
ANSWERS, SOMETIMES ADDITIONAL--
EVEN MORE TESTS ARE GOING
TO BE SUGGESTED, SUCH AS
A SLEEP STUDY, BUT MORE--
IT'S DESIGNED
TO BETTER IDENTIFY
DISORDERS IN SLEEP.
SO I'LL JUST MENTION
THAT THE INCIDENCE
OF EPILEPSY VARIES BY AGE.
IT'S HIGHEST--THE GREATEST
NUMBER OF INDIVIDUALS
DEVELOP EPILEPSY
AT VERY YOUNG AGES,
IMMEDIATELY AFTER BIRTH
AND DURING SCHOOL AGE,
BUT THERE'S ALSO
AN INCREASE IN EPILEPSY
AND THE INCIDENCE OF SEIZURES
IN EPILEPSY AS PEOPLE AGE.
AND IT'S BECOME APPARENT
THAT AS PEOPLE AGE, LIKE,
AS I MENTIONED, THE INCIDENCE
OF EPILEPSY INCREASES
AND IT GETS HIGHER
AND HIGHER THROUGHOUT LIFE.
AND THIS IS DUE TO STROKES
AS WELL AS NEURO-DEGENERATIVE
DISEASES SUCH AS ALZHEIMER'S,
WHICH CAN PREDISPOSE PEOPLE
TO SEIZURES AND EPILEPSY.
THE CAUSES OF EPILEPSY
ALSO VARY BY AGE.
SO, IN THE VERY YOUNG,
PERINATAL INJURIES
SUCH AS BIRTH ASPHYXIA,
METABOLIC DEFECTS,
AND CONGENITAL MALFORMATIONS
THAT ARISE FROM ABNORMALITIES
IN DEVELOPMENT SUCH AS
CEREBRAL PALSY--
THOSE ARE THE MOST IMPORTANT
CAUSES OF EPILEPSY.
INFECTION IN THE CNS IS
AN IMPORTANT CAUSE OF EPILEPSY
AS WELL IN THIS AGE GROUP.
AS WE LOOK
AT OLDER INDIVIDUALS,
THE MOST IMPORTANT CAUSES
OF EPILEPSY ARE HEAD TRAUMA,
WHICH IS THE NUMBER-ONE
CAUSE OF EPILEPSY
IN THE AGE GROUP BETWEEN
15 TO 40 YEARS OLD;
AS WELL AS CEREBRAL VASCULAR
DISEASE, OR STROKES;
AND BRAIN TUMORS.
SO OFTEN, WE CAN ASCRIBE
SEIZURES IN EPILEPSY
TO A SPECIFIC IDEOLOGY.
BUT EVEN WITH OUR ADVANCED
NEURO-IMAGING TECHNIQUES
AND AN EVER-INCREASING BATTERY
OF TESTS THAT WE CAN USE,
IN ABOUT HALF THE CASES,
A LITTLE MORE THAN HALF
THE CASES, WE REALLY
DON'T KNOW THE CAUSE.
NO IDENTIFIABLE CAUSE
FOR THE SEIZURES AND EPILEPSY
CAN BE FOUND, AND WE CALL
THAT TYPE OF EPILEPSY
CRYPTOGENIC EPILEPSY.
WE BELIEVE THERE'S A CAUSE,
BUT WE JUST CAN'T
CONVINCINGLY DEMONSTRATE
WHAT THAT IS.
AND I'LL JUST MENTION,
GENETIC FORMS OF EPILEPSY
ARE BECOMING
INCREASINGLY RECOGNIZED.
IN FACT, WE'RE LEARNING MORE
AND MORE ABOUT THESE TYPES--
THIS CAUSE OF EPILEPSY,
AND AS TIME GOES ON,
WE'RE PROBABLY GOING TO HAVE
MORE AND MORE OPPORTUNITY
TO IDENTIFY GENETIC
CAUSES OF EPILEPSY.
GENETIC CAUSES OF EPILEPSY ARE
TYPICALLY SEEN AT YOUNGER AGES,
IN SCHOOL AGE AND TEENAGE
UP TO 20 YEARS OLD.
SO WHEN SOMEONE DEVELOPS
SEIZURES AND EPILEPSY
LATER IN LIFE--SAY,
THEIR 30s, 40s, 50s, 60s--
WE TYPICALLY DON'T THINK
OF GENETIC CAUSES,
BUT, OF COURSE, THAT CAN BE
POSSIBLE IN SOME INSTANCES.
AND AS IT RELATES
TO THE CAUSE OF EPILEPSY,
WE ALWAYS REVIEW SEIZURE RISK
FACTORS, WHICH INCLUDE PROBLEMS
OF DEVELOPMENTAL PROBLEMS, WE
TAKE A DETAILED BIRTH HISTORY,
WHETHER THERE WERE PROBLEMS
DURING THE WOMAN'S PREGNANCY,
WHETHER THERE WAS ANY
COMPLICATIONS DURING DELIVERY.
SEVERAL OF THESE ARE
VERY COMMON,
AND MOST PEOPLE DON'T GO ON
TO DEVELOP EPILEPSY.
NONETHELESS, THAT IS
AN IMPORTANT RISK FACTOR
FOR THE LATER DEVELOPMENT
OF EPILEPSY, PARTICULARLY
IF THE FEBRILE SEIZURE
WAS PROLONGED,
LONGER THAN 30 MINUTES,
OR IF IT HAS WHAT WE CALL
FOCAL FEATURES, SUCH AS IT
STARTED ON ONE SIDE OF THE BODY.
I MENTIONED THAT WE ALWAYS ASK
ABOUT HEAD TRAUMA AND INFECTIONS
THAT INVOLVE THE CENTRAL
NERVOUS SYSTEM,
SUCH AS MENINGITIS
AND ENCEPHALITIS.
LEARNING ABOUT ANY FAMILY
HISTORY OF EPILEPSY IS
ALSO VERY IMPORTANT AND IT'S
SOMETHING THAT IF YOU'RE
SEEING A PHYSICIAN, THE MORE
INFORMATION YOU CAN PROVIDE
ABOUT FAMILY MEMBERS WITH
SEIZURES AND EPILEPSY,
THAT'S VERY HELPFUL TO THE
PHYSICIAN TO DETERMINE
WHETHER OR NOT THIS IS
RELEVANT TO THE FEATURES
IN EPILEPSY
UNDER CONSIDERATION.
SO WHAT TYPES
OF SEIZURES ARE THERE?
WELL, I MENTIONED EARLIER
THAT WE COULD SEE ON AN EEG
ABNORMAL ELECTRICAL ACTIVITIES
THAT DEVELOP SIMULTANEOUSLY
ON BOTH SIDES OF THE BRAIN,
AND WE CALL THOSE
GENERALIZED SEIZURES
OR GENERALIZED ONSET SEIZURES.
THESE CAN COME,
SOME OF THEM, IN TIDES.
THEY CAN CAUSE WHAT WE CALL
MYOCLONUS, SIMPLE JERKING
MOVEMENTS THAT MAYBE NOT EVEN
CAUSE LOSS OF AWARENESS.
SOMETIMES THESE GENERALIZED
SEIZURES CAN SIMPLY CAUSE
BEHAVIORAL ARRESTS,
OR AN INDIVIDUAL WILL STOP
WHAT THEY'RE DOING AND HAVE
A BLANK STARE FOR A FEW MOMENTS
AND THEN RECOVER RAPIDLY
AND COMPLETELY.
THOSE TYPES OF SEIZURES ARE
TERMED ABSENT SEIZURES,
AND WHEN NEUROLOGISTS TALK
ABOUT ABSENCE SEIZURES,
WE'RE REALLY TALKING
ABOUT A SPECIFIC DIAGNOSIS--
ABSENCE EPILEPSY, WHICH IS
A TYPE OF GENERALIZED SEIZURE.
GENERALIZED SEIZURES CAN
ALSO CAUSE GRAND MAL SEIZURES,
OR THE GENERALIZED
TONIC-CLONIC SEIZURES
THAT WILL INVOLVE
MAJOR MOTOR ACTIVITY.
IT CAN CAUSE PEOPLE TO FALL TO
THE GROUND AND SUFFER INJURY,
AND OFTEN ARE ASSOCIATED
WITH TONGUE-BITING
AND LOSS OF URINARY CONTINENCE.
IN CONTRAST TO THOSE
GENERALIZED ONSET SEIZURES,
SEIZURES THAT START
ON BOTH SIDES OF THE BRAIN
AT THE SAME TIME, THERE ARE
ALSO FOCAL SEIZURES,
HISTORICALLY CALLED
PARTIAL ONSET SEIZURES.
AND THE NAME "FOCAL"
APPLIES AS THEY START
IN A SPECIFIC LOCATION
IN THE BRAIN--
SUCH AS THE RIGHT TEMPORAL
LOBE, FOR EXAMPLE--
AND A SEIZURE THAT STARTS
FOCALLY, THEY CAN STAY IN
THAT LOCATION AND SPREAD LOCALLY
AND CAUSE A SET OF SYMPTOMS.
FOCAL SEIZURES
ARE WHAT PRODUCE AURAS,
SO WHEN PEOPLE HAVE AN AURA,
OR A WARNING SYMPTOM
BEFORE THEIR SEIZURE, THAT IS
ACTUALLY THE FOCAL PART
OF THE SEIZURE, WHERE THEY'RE
EXPERIENCING SYMPTOMS RELATED
TO THE SEIZURE DEVELOPING IN
A SPECIFIC PART OF THE BRAIN.
IF THEY SPREAD LOCALLY,
THEY CAN THEN CAUSE SOME
OF THESE REPETITIVE MOVEMENTS
THAT WE SPOKE OF EARLIER
THAT CAN CAUSE LOSS OF AWARENESS
AND RESPONSIVENESS,
AND DEPENDING ON
WHAT PART OF THE BRAIN,
THEY COULD CAUSE A WHOLE HOST
OF OTHER SYMPTOMS,
INCLUDING AN INABILITY
OF SPEECH,
MAYBE AN ABNORMAL
POSTURING OF ONE LIMB.
SOMETIMES THERE CAN BE
LIP-SMACKING MOVEMENTS
OR TWITCHING
OF ONE SIDE OF THE FACE,
SO THESE ARE ALL SYMPTOMS
DUE TO FOCAL SEIZURES.
THERE'S BEEN A RECENT CHANGE
IN THE TERMINOLOGY,
BUT I THINK THE TERMS
THAT WERE PREVIOUSLY USED
OF COMPLEX PARTIAL SEIZURE
VERSUS SIMPLE PARTIAL SEIZURE--
AT LEAST WARRANT MENTIONING.
SO THE TERM COMPLEX PARTIAL
SEIZURE IS USED TO DESCRIBE
A FOCAL SEIZURE, A SEIZURE
THAT BEGINS AND STAYS
IN ONE AREA IN THE BRAIN,
BUT WE CALL IT COMPLEX
BECAUSE IT INVOLVES
A LOSS OF AWARENESS
OR AN ALTERATION OF AWARENESS.
AND THAT'S TO BE CONTRASTED WITH
SIMPLE PARTIAL SEIZURES,
AND SIMPLE PARTIAL SEIZURES ARE
REFERRING TO SEIZURES
THAT CAUSE A SYMPTOM IN ONE PART
OF THE BODY, SUCH AS JERKING
OF ONE LIMB OR TWITCHING
OF ONE SIDE OF THE FACE,
BUT THEY DO NOT ALTER AWARENESS
OR CONSCIOUSNESS AT ALL.
SO AN INDIVIDUAL EXPERIENCING
SIMPLE PARTIAL SEIZURE IS GOING
TO BE FULLY CONVERSANT
AND REMEMBER EVERYTHING,
BUT THEY'LL HAVE THIS
SYMPTOM THAT IS DUE TO
AN ABNORMAL PATTERN
OF ELECTRICAL ACTIVITY
IN A SPECIFIC PART OF THE BRAIN.
FOCAL SEIZURES DON'T
ALWAYS SPREAD LOCALLY,
AND THEY CAN SPREAD OUT
AND INVOLVE THE ENTIRE BRAIN,
AND WE CALL THIS A SECONDARILY
GENERALIZED SEIZURE.
AND SO A SEIZURE CAN START
FOCALLY AND THEN SPREAD TO
INVOLVE THE ENTIRE BRAIN AND
CAUSE A GRAND MAL SEIZURE, WHICH
IS ALSO CALLED A GENERALIZED
TONIC-CLONIC SEIZURE.
SO, AGAIN, SEIZURES ARE BROADLY
CLASSIFIED AS FOCAL AT ONSET,
WHICH WOULD BE SIMPLE
PARTIAL SEIZURES,
WHICH WOULD INCLUDE AURAS;
COMPLEX PARTIAL SEIZURES
AND COMPLEX PARTIAL SEIZURES
WITH SECONDARY GENERALIZATION;
OR THEY CAN BE GENERALIZED AT
ONSET, CAUSE GRAND MAL SEIZURES,
THEY COULD CAUSE ABSENCE
SEIZURES, AND OTHER FORMS
OF SEIZURES THAT ARE
PROBABLY LESS COMMON,
SUCH AS MYOCLONIC
AND TONIC SEIZURES.
CLASSIFICATION OF EPILEPSY
IS REALLY AN EXTENSION
OF THE TYPE OF SEIZURE,
SO WE CLASSIFY EPILEPSY
AS EITHER BEING FOCAL
OR GENERALIZED.
IN THE RECENT CLASSIFICATION
SCHEME PUT FORTH BY
THE INTERNATIONAL LEAGUE
AGAINST EPILEPSY,
THERE'S A LOT OF MORE SPECIFIC
SYNDROMES THAT ARE DEFINED.
I'M NOT GOING TO GO
INTO THOSE TODAY,
BUT THEY HAVE THEN PRODUCED
TO RECOGNIZE THE INCREASED
UNDERSTANDING
OF GENETIC CAUSES OF EPILEPSY
AND WHAT THE CAUSE
OF THE EPILEPSY IS.
SO, WHAT TO DO WHEN
AN INDIVIDUAL HAS A SEIZURE?
AS I MENTIONED,
MOST OF THE TIME,
SEIZURES WILL STOP ON THEIR OWN.
SO SEIZURES THAT LAST LONGER
THAN TWO MINUTES ARE
FAIRLY UNUSUAL,
BUT THE MAIN GOAL IS
TO KEEP AN INDIVIDUAL SAFE,
AND RIGHT NOW I'M TALKING
ABOUT GENERALIZED
TONIC-CLONIC SEIZURES.
SO IF SOMEONE HAS A SEIZURE,
AND THE SEIZURE STARTS,
SHOULD TRY TO HELP THEM
AVOID INJURY, LOWER THEM
TO THE GROUND AND,
IF POSSIBLE, ROLL THEM
ONTO THEIR LEFT SIDE.
WHEN YOU ROLL INDIVIDUALS
ONTO THEIR SIDES TO REDUCE
THE RISK OF ASPIRATION,
OR SWALLOWING SALIVA--
HAVING SALIVA FALL INTO
THE LUNGS, WHICH CAN CAUSE
A WHOLE OTHER HOST OF PROBLEMS.
DURING A SEIZURE, INDIVIDUALS
ARE NOT SWALLOWING
AND MANAGING THEIR
ORAL SECRETIONS NORMALLY,
SO THERE'S A RISK
OF THIS HAPPENING,
WHAT YOU CALL ASPIRATION.
AND, AGAIN, MOST SEIZURES
STOP ON THEIR OWN.
IF SOMEONE HAS--AN INDIVIDUAL--
A SINGLE SEIZURE,
IT'S A TYPICAL SEIZURE FOR THEM
THAT LASTS A COUPLE MINUTES
AND THEN STOPS AND RESOLVES,
IT'S ALWAYS ADVISABLE
TO CALL THE INDIVIDUAL'S
NEUROLOGIST
AND DESCRIBE THIS TO THEM.
BUT THERE'S NOT
NECESSARILY A NEED TO GO
TO THE EMERGENCY DEPARTMENT.
SOME OF YOU MAY HAVE
EXPERIENCED TRIPS
TO THE EMERGENCY DEPARTMENT
AND, YOU KNOW, THESE ARE
TIME-CONSUMING, EXPENSIVE TRIPS
THAT OFTEN DON'T
PRODUCE MUCH BENEFIT.
AND I SAY THAT BECAUSE--THE E.R.
PHYSICIANS ARE EXCELLENT
AT TREATING A SEIZURE THAT'S
HAPPENING IN FRONT OF THEM,
BUT FOR TREATING EPILEPSY,
THEY MAY NOT DO A WHOLE LOT.
AND LIKE I SAY,
IF THE SEIZURE'S OVER
AND YOU GO TO THE EMERGENCY
DEPARTMENT, AN INDIVIDUAL'S
FEELING WELL, NOT HAVING
ANY SYMPTOMS, AND THEY MAY DO
SOME BLOOD WORK AND
OBSERVE FOR A LITTLE BIT,
BUT THEY MAY NOT EVEN RECOMMEND
ANY CHANGE IN THERAPY
AND JUST SIMPLY SUGGEST
THAT YOU FOLLOW UP
WITH YOUR NEUROLOGIST.
I NEVER TELL MY PATIENTS NOT TO
GO TO THE EMERGENCY DEPARTMENT
IF THEY'RE AFRAID OR SOMETHING
IS REALLY CONCERNING,
BUT I THINK IT'S IMPORTANT TO
EMPOWER PEOPLE NOT TO DO THAT,
THAT IT'S NOT
ALWAYS NECESSARY,
THAT IT'S OK IF A SEIZURE
HAPPENS AND STOPS.
THERE'S NOT A HUGE NEED TO GO
TO THE EMERGENCY DEPARTMENT.
THAT'S NOT ALWAYS THE CASE,
THOUGH, AND PARTICULARLY
FOR SEIZURES THAT LAST
LONGER THAN 5 MINUTES,
OR IF AN INDIVIDUAL HAS TWO
OR MORE SEIZURES IN A ROW
WITHOUT COMPLETELY RECOVERING
IN BETWEEN THE EVENTS,
THOSE ARE SITUATIONS WHERE
IT IS ALWAYS APPROPRIATE
TO SEEK MEDICAL ATTENTION,
PARTICULARLY IF A SEIZURE
IS CONTINUING
LONGER THAN 5 MINUTES.
THAT'S SORT OF THE
OPERATIONAL DEFINITION
OF STATUS EPILEPTICUS,
WHICH IS A SEIZURE
THAT IS NOT STOPPING ON ITS OWN.
AND THAT'S A MEDICAL EMERGENCY,
AND SO IF A SEIZURE LASTS LONGER
THAN 5 MINUTES AND IT'S NOT
STOPPING, IT'S ALWAYS INDICATED
TO CALL THE PARAMEDICS
OR GET THE PATIENT
TO BE SEEN BY A DOCTOR.
AND I THINK AT THIS POINT, I'VE
COVERED MOST OF THE ITEMS
I'VE WANTED TO DISCUSS,
AND IT WOULD BE APPROPRIATE
TO OPEN UP TO QUESTIONS
SO I CAN MAYBE DESCRIBE SOME
OF THE THINGS I MENTIONED
IN GREATER DETAIL
OR ADDRESS OTHER QUESTIONS
PEOPLE HAVE.
- I'M GOING TO OPEN UP
FOR QUESTIONING.
HOLD ON A SECOND.
- SURE.
- ALL RIGHT, DOCTOR.
THE LINES SHOULD BE
OPEN FOR QUESTIONS.
- OK. TERRIFIC.
- DOES ANYBODY HAVE
ANY QUESTIONS?
- I'LL BE HAPPY TO ANSWER ANY
QUESTIONS IF ANYONE HAS THEM.
- ALL RIGHT, SIR.
I DON'T THINK THERE'S
ANY QUESTIONS.
- DID ANYONE ELSE LOG IN, EVEN?
- YEAH, THERE WAS
OTHER PEOPLE ON THE CALL.
I DON'T HAVE
THE FINAL NUMBERS YET.
- OK. WELL,
THAT'S DISAPPOINTING,
BUT I HOPE IT WASN'T TOO BORING
AND TOO BASIC FOR THEM,
BUT--HA HA HA!
THAT'S ALL RIGHT, I GUESS.
- IT WAS VERY GOOD, SIR.
- OK, THANK YOU.
- THANK YOU.
- THANK YOU, DR. RANSOM.
- OK, YOU'RE
VERY WELCOME. BYE-BYE.
- BYE-BYE.